HomeMy WebLinkAboutR2021-0159 - Permit ApplicationPrint Form
City of Newport Beach
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
262�� 100 Civic Center Drive I P.O. Box 17681 Newport Beach, CA92658-8915
RBR# www.newportbeachea.gov 1 (949) 644-3200
Application for Report of Residential Building Records
Application Fee: - $194.00 Notice:
(For All Residential Buildings) Applications with insufficient fee payment
Reinspection Fee $129.00 or incomplete will be returned
ProperWOwner:ljcimison-Jnves+-Neter_/jocii DCR-Oq Zip Code:
Owner Address: '�ZUc )G, city: ��4Y1e
i --
State: CA _ Zip Code: q Zo2 i Home Phone: ------ '"-
Owner's Authorized Agent: I Work Phone:
Agent Address: I City:
State: F Zip Code: F Agent Email Address:
Escrow Company: pQ�r 6I I V M W Escrow #:I Ns - IIJW 02 - 2Z
Escrow Address: vppkr P Ln a -,, 1 City: N .e weo , -t '��,ck
State: C� /_� Zip Code:Fc/'2G 66 Escrow Phone: q',4 2--o cyjz4b
Email Report to:c✓
r'1 Q Y1 �' , Cl CGl'Sii t U pnr-f - - I
For Inspection call (Name): J od I Df I WO Direct Phonet9 `4 G-
!5�
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections of the property listed above. I understand that if Building orZoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
Date:
OR
Owner/Agent's signature to decline inspection: Date: F—T.—®
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building_DiWsionftms\RBR 7.3040
Please type or print and complete
all information
# of Units: I l i Address:
City: Newport Beach J State:
CA Zip:
2- -Z
2!,-n � c Ir F c- ic)-
ProperWOwner:ljcimison-Jnves+-Neter_/jocii DCR-Oq Zip Code:
Owner Address: '�ZUc )G, city: ��4Y1e
i --
State: CA _ Zip Code: q Zo2 i Home Phone: ------ '"-
Owner's Authorized Agent: I Work Phone:
Agent Address: I City:
State: F Zip Code: F Agent Email Address:
Escrow Company: pQ�r 6I I V M W Escrow #:I Ns - IIJW 02 - 2Z
Escrow Address: vppkr P Ln a -,, 1 City: N .e weo , -t '��,ck
State: C� /_� Zip Code:Fc/'2G 66 Escrow Phone: q',4 2--o cyjz4b
Email Report to:c✓
r'1 Q Y1 �' , Cl CGl'Sii t U pnr-f - - I
For Inspection call (Name): J od I Df I WO Direct Phonet9 `4 G-
!5�
CONSENT TO INSPECT (FORM MUST BE SIGNED & DATED BELOW)
I authorize inspections and re -inspections of the property listed above. I understand that if Building orZoning
violations are discovered I will be responsible to correct said violations.
Owner/Agent's signature to authorize inspection:
Date:
OR
Owner/Agent's signature to decline inspection: Date: F—T.—®
Account # 01050504-521040 .................Make checks payable to: CITY OF NEWPORT BEACH
Building_DiWsionftms\RBR 7.3040